Browsing by Author "Ortiz, Jorge"

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An International Survey of the Diagnosis, Management, and Treatment of Hepatitis C in Patients with End-Stage Renal Disease
(Başkent Üniversitesi, 2009-12) Araya, Victor; Ortiz, Jorge; Olson, Mira R.; Grewal, Kevin S.; Bingaman, Adam; Zaki, Radi; Stewart, Shelby; Horton, John
Objectives: Hepatitis C is one of the leading causes of death from liver disease in the United States, and is frequently associated with renal disease. Two major organizations—the American Association for the Study of Liver Disease and the National Kidney Foundation—have published recommendations regarding the treatment of hepatitis C in the presence of chronic kidney disease; however, these guidelines do not always provide the same recommendations. Given the paucity of data on adherence to the current guidelines, a survey was conducted to provide information about the current practices of physicians in comparison to the published guidelines. Materials and Methods: An observational study was conducted via a global survey asking physicians treating patients who had concurrent hepatitis C and chronic kidney disease. Results: The 218 questionnaires collected requested the physician’s subspecialty, the number of transplants performed at the hospital, the usual method of screening for hepatitis C, the preferred route, the indication and frequency of liver biopsy, the use of ribavirin and interferon, the use of hepatitis-C–positive donors in kidney transplant, and consent requirements. Conclusions: Our results showed that many physicians do not follow current recommendations. We argue that a consensus group be formed to set forth guidelines for the management of hepatitis C to optimize outcomes, and improve overall morbidity.
Cutaneous Metastasis of Pancreatic Adenocarcinoma After Kidney Transplant: A Case Report and Review of the Literature
(Başkent Üniversitesi, 2010-12) Pontinen, Thomas; Ortiz, Jorge; Zaki, Radi; Kung, Shiang Cheng; Chewaproug, Daranee; Khanmoradi, Kamran; Varadi, Gabor; Melin, Alyson
Objectives: Pancreatic cancer is one of the most lethal human cancers. Each year in the United States, about 42 470 individuals are diagnosed with this condition, and 35 240 die, despite advances in imaging, medical treatment, and surgical intervention. Often, 80% to 90% of pancreatic cancers are diagnosed at the locally advanced or metastatic stage. However, cutaneous metastases originating from pancreatic cancer are rare. If cutaneous metastases do indeed occur, it is often near the umbilicus, known as the Sister Mary Joseph’s nodule. Nonumblical cutaneous metastases are rare, with only several cases reported, but none regarding lesions after organ transplant. We introduce the first reported case of a cutaneous metastatic lesion of pancreatic adenocarcinoma after the transplant of an organ. We also performed a literature review and an analysis of reported cases of nonumblical cutaneous metastases of pancreatic adenocarcinoma. Materials and Methods: We performed a MEDLINE and PubMed search of reported nonumblical cutaneous metastases of pancreatic adenocarcinoma since 1980 after a literature review and analysis. Results: Our case involved a 76-year-old woman who developed cutaneous pancreatic adenocarcinoma metastases in her surgical wound 2 years after a bilateral kidney transplant. This is the first case of pancreatic adenocarcinoma cutaneous metastases after an organ transplant. Conclusions: The death rate from cancer has increased as the population has aged. This also holds true for transplant recipients. Some believe that cancer will soon surpass cardiovascular disease as the major cause of mortality after transplant. Therefore, it is incumbent upon us to appropriately screen patients with age-appropriate evidence-based examinations. Additionally, those patients with suspicious presentations should be judiciously evaluated to discover a cure for cancer as quickly as possible.
Early Allograft Biopsies Performed During Delayed Graft Function May Not Be Necessary Under Thymoglobulin Induction
(Başkent Üniversitesi, 2012-06) Ortiz, Jorge; Chewaproug, Daranee; Balasubramanian, Manju; Zaki, Radi; Campos, Stalin; Feyssa, Eyob; Khanmoradi, Kamran; Mumtaz, Khurram; Parsikia, Afshin
Objectives: Delayed graft function affects up to 50% of kidney transplant recipients. Some guidelines recommend surveillance biopsies beginning 7 days after engraftment. This may be unnecessary with anti-thymocyte globulin induction. Materials and Methods: We conducted a retrospective study of deceased-donor renal transplant recipients with delayed graft function. Results: One hundred eleven patients met the inclusion criteria. The incidence of rejections during delayed graft function was 2.7%. They were diagnosed between 9 and 11 days after transplant. The subsequent incidence of rejection at 12-month follow-up was 13.5% (n=15). The median time to rejection after transplant was 10 weeks. Fourteen of 15 patients had subtherapeutic immunosuppression. The only risk factor associated with later rejection after delayed graft function was use of donors after cardiac death. Conclusions: Early rejection during delayed graft function with anti-thymocyte globulin induction and maintenance immunosuppression with tacrolimus, mycophenolate mofetil, and steroids is rare. When later rejection occurs, it is at a median of 10 weeks after a transplant. Two of the 3 early rejections were antibody mediated. Later rejections were associated with subtherapeutic immunosuppression and donors after cardiac death. Biopsies need not be performed during the early postoperative period when anti-thymocyte globulin is used with tacrolimus, mycophenolate mofetil, and steroids.
Horseshoe Kidneys: An Underutilized Resource in Kidney Transplant
(Başkent Üniversitesi, 2010-03) Zaki, Radi; Ortiz, Jorge; Pontinen, Thomas; Khanmoradi, Kamran; Kumar, Anil; Kudsi, Hussam; Kung, Shiang Cheng; Chewaproug, Daranee
Objectives: Although the number of patients awaiting renal transplant is rapidly increasing, the donor pool has remained relatively stable. Horseshoe kidneys, a common renal fusion anomaly, can provide a useful solution to the ever-increasing gap between supply and demand. Materials and Methods: These kidneys can be transplanted, en bloc, into a single recipient or divided and transplanted into 2 recipients. Results: We report 2 cases of successful kidney transplants. Conclusions: The first is a split horseshoe kidney, transplanted into a single recipient, and the second, a horseshoe kidney from a donor after cardiac death split and transplanted into a single recipient. The second case is the first reported case of a horseshoe kidney transplant from a donor after cardiac death. We also performed a review of the literature of horseshoe kidneys with the hope of raising awareness of the necessity and promise of such transplants.
Perioperative Management of Spontaneous Splenorenal Shunts in Orthotopic Liver Transplant Patients
(Başkent Üniversitesi, 2012-10) Awad, Nadia; Fishman, Michael D. C.; Ortiz, Jorge; Zaki, Radi; Brady, Paul; Parsikia, Afshin; Horrow, Mindy M.
Objectives: Spontaneous splenorenal shunts cause significant vascular steal from the liver. There is no accepted algorithm for treating spontaneous splenorenal shunts before, during, or after liver transplant, and evidence for efficacy of treatments remains limited. Materials and Methods: We reviewed the literature, and our institution’s experience regarding spontaneous splenorenal shunts, including a case series of 6 patients with spontaneous splenorenal shunts undergoing transjugular intrahepatic porto-systemic shunts, a case of intraoperative ligation of a large spontaneous splenorenal shunts during transplant, and 1 patient requiring multiple endovascular interventions to embolize recurrent spontaneous splenorenal shunts after orthotopic liver transplant. Results: Small spontaneous splenorenal shunts may not need intervention, as involution after liver transplant is well known. Transjugular intrahepatic porto-systemic shunts may decrease the porto-systemic gradient in patients with large spontaneous splenorenal shunts, as shown in our review of 6 patients with large spontaneous splenorenal shunts undergoing transjugular intrahepatic porto-systemic shunts. We have demonstrated re-establishment of physiologic flow after ligation of a large spontaneous splenorenal shunt at the time of transplant, supporting operative ligation may be justified if intraoperative compression of the spontaneous splenorenal shunts demonstrates significant improvement of allograft portal venous flow. Ligation of the left renal vein for large spontaneous splenorenal shunts is a safe and effective method of preventing portal venous steal. For concomitant spontaneous splenorenal shunts and portal vein thrombosis, renoportal anastomosis can be performed. We report transient success with endovascular embolization of large spontaneous splenorenal shunts in a patient posttransplant who required multiple interventions. Conclusions: Experience in the approach to and treatment of spontaneous splenorenal shunts in liver transplant recipients is limited. Further investigation into the best approach to treat spontaneous splenorenal shunts is warranted as the presence and persistence of spontaneous splenorenal shunts can lead to allograft dysfunction and possible allograft loss.
Posttransplant Lymphoproliferative Disease Presenting as Adrenal Insufficiency: Case Report
(Başkent Üniversitesi, 2005-06) Khan, Abdaal; Ortiz, Jorge; Jacobson, Laura; Reich, David; Manzarbeitia, Cosme
This is the first reported case of lymphoproliferative disease presenting with adrenal insufficiency after liver transplantation. A 38-year-old white man was admitted 8 months after transplantation for cryptogenic cirrhosis with fever (38-39°C), chills, cough, and dyspnea. His blood pressure was 100/70 mm Hg, there was pallor of the conjunctiva, and a lymph node was palpable in the left groin. Laboratory analyses revealed the following values: serum sodium concentration (112 mmol/L), potassium (5.4 mmol/L), hemoglobin (7.8 g/L), white blood cell count (7.7 x 109/L), glucose 3.9 (mmol/L), and mildly elevated liver functions. Abdominal ultrasound showed multiple hypoechoic solid-appearing lesions throughout the liver and spleen. Results of a biopsy specimen of the groin node confirmed polymorphic B-cell lymphoma. A negative Epstein-Barr virus screen before transplant became positive. The patient’s fever increased to 40°C. He subsequently developed sepsis and later, multiple organ failure. Autopsy confirmed extensive abdominal disease. The adrenal glands had been completely replaced by the tumor. Primary Epstein-Barr virus infection is associated with posttransplant lymphoproliferative disease. Replacement of the adrenal glands with a tumor produces a clinical picture of adrenal insufficiency.
Severe Hepatitis C Virus Recurrence Is Nearly Universal After Donation After Cardiac Death Liver Transplant
(Başkent Üniversitesi, 2011-04) Ortiz, Jorge; Araya, Victor; Balasubramanian, Manjula; Zaki, Radi; Khanmoradi, Kamran; Campos, Stalin; Hashemi, Nikroo; Azhar, Ashaur; Parsikia, Afshin; Feyssa, Eyob L.
Objectives: The rate of hepatitis C virus recurrence after donation after cardiac death liver transplant is not clearly defined. Materials and Methods: This is a retrospective review of 39 donations after cardiac death-liver transplant recipients. Biopsies were performed at 6, 12, 24, and 36 months for all hepatitis C virus positive donation after cardiac death recipients. Results: The 6-, 12-, 24-, and 36-month severe hepatitis C virus recurrence rates were 60%, 73%, 87%, and 94%. A histologic comparison group of 26 long-surviving hepatitis C virus positive donation after neurologic death recipients had severe hepatitis C virus recurrence 27%, 31%, 42%, and 52% of the time. Six of the 19 hepatitis C virus donation after cardiac death patients developed cirrhosis at a median of 56 months (range, 14-119 months). There was no significant 3-year allograft and patient survival difference between hepatitis C virus and nonhepatitis C virus donation after cardiac death recipients. The factors most associated with decreased survival in the entire cohort included biliary and vascular complications. Organs procured by our institution’s attending surgeons were associated with a better 3-year allograft survival. Conclusions: Severe hepatitis C virus recurrence was nearly universal but did not lead to increased graft loss when compared with nonhepatitis C virus donation after cardiac death at 3 years. These data may justify early interferon treatment in these at-risk patients.
Soft Tissue Sarcoma at a Dialysis Access Site in a Transplant Recipient
(Başkent Üniversitesi, 2012-08) Andre, Jason; Campos, Stalin; Ortiz, Jorge; Zaki, Radi; Khanmoradi, Kamran; Minimo, Corrado; Parsikia, Afshin
Soft tissue sarcomas typically present as soft, painless masses on an extremity. Here, we present a patient with metastatic soft tissue sarcomas at his dialysis access site. This association with dialysis access has not been documented previously. A 62-year-old man presented with a nonhealing wound on his left upper extremity after excision of a pseudoaneurysmal arteriovenous fistula. The patient had received a second kidney transplant that was functioning well. Immunosuppression included tacrolimus, mycophenolate mofetil, and prednisone. He was induced with thymoglobulin twice. A biopsy was performed showing a high-grade pleomorphic sarcoma. A magnetic resonance image of his left upper extremity showed an 11 × 5.5 × 3 cm mass abutting the biceps and brachialis muscles. Also, we discovered several lesions in the axilla and the left side of the neck, which were suspicious for metastases. A positron emission tomography-computed tomography scan confirmed a left upper extremity soft tissue mass, with marked fluorodeoxyglucose uptake, in abnormally enlarged axillary, and supraclavicular lymph nodes of the left thorax, consistent with metastases. The patient underwent chemotherapy and radiation therapy.